As a rule, I will not disclose any information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. In the event you or someone else request me to give a third party information I will require your permission by having you sign a Release of Information form. You may revoke your permission, in writing, at any time, by contacting me.

There are Limits of Confidentiality

There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, [some because of policies in this office/agency], and some required by law. If you wish to receive mental health services from me, you must sign a form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues prior to beginning our work together but you may reopen the conversation at any time during our work together.

I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:

Emergency: If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.

Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Pennsylvania law to report the matter immediately to the Philadelphia Department of Human Services, Children and Youth Division and/or the police.

Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Pennsylvania law to immediately make a report and provide relevant information to the Philadelphia Corporation for Aging and/or police.

Suicidal or Homicidal: If you threaten to harm yourself or you threaten a specific person that can be identified, I am required by Pennsylvania law to report the matter immediately to the law and to the person you are threatening. In circumstances where you are threatening to harm yourself I may have to have to you 302'd (involuntarily hospitalized).